Laparoscopic surgery (which is also known as minimal invasive surgery (MIS)) has become increasingly popular over the last few years due to its benefits, including lower morbidity, less perceived pain, better cosmetic results and less hospital time. Laparoscopic surgery is one of the most commonly performed minimally invasive surgeries worldwide. Since its beginning, the advantages over an open surgical approach include, decreased pain, fewer postoperative complications, decreased length of hospitalization, better intra-abdominal visualization and better cosmetics are widely known and appreciated.
In laparoscopic surgery, small incisions, typically about 5 to about 15 millimeters in length, are made in the abdominal wall for the insertion of trocar ports (or other similar devices), which are thin tubes that span the thickness of the abdominal wall and allow for the insertion and extraction of the tools needed to perform the surgery.
In order to perform the surgery, the abdominal wall is pressurized with a gas (carbon dioxide) to a pressure of between about 10 and about 20 mm Hg to create a working space between the internal organs and the peritoneum. Typically the first tool introduced into and the last tool to be extracted from the abdominal cavity is an endoscope with its built in light source. The endoscope sends video images to a monitor that is used by the surgeon and medical staff to watch the introduction of other tools and, to make sure that such tools are properly introduced with no or minimal tissue damage.
In most laparoscopic surgeries, there are typically at least three tools that are required to perform the surgery—an endoscope, a grasper or lifter, and a cutting tool, which may be a scissor tool or electro-cautery. Furthermore, in a traditional laparoscopic surgical process, each tool that is needed/used requires its own trocar port. In addition, if access to a particular location is not possible from a current port, either a new port must be inserted or the tool in one of the other ports must be removed and then reinstalled.
There is always a risk of puncturing vital organs or blood vessels during the insertion of the trocar ports. Also, the repositioning of tools or the insertion of another port can result in a delay in the progress of the surgery, causing the patient to be under anesthesia for longer time periods and causing delays for the surgeon.
In the case of laparoscopic appendectomies, the classic laparoscopic technique typically utilizes three ports, which most commonly include one 12 mm and two 5 mm ports. The first port allows a laparoscope for visualization, the second harbors an instrument for dissection and the last port facilitates the use of an instrument for retraction of the appendix.
Over the past few years efforts have been made to reduce the number of ports required from three to two ports, or even a single port, and two-port techniques, hybrid approaches, and single-port assisted techniques have been developed in this regard. The two-port appendectomy technique is very similar to the standard three-port technique with the exception of one port allowing access for a rigid endoscope with a working channel and a second port that is used for a grasping instrument to provide retraction of the appendix.
In the hybrid technique, laparoscopy is combined with standard open techniques and the appendix is pulled out through the umbilicus in children or a right lower quadrant incision in adults to perform a traditional open appendectomy extracorporeally. The hybrid technique in which the appendix is pulled through a single incision in the umbilicus is only possible in the pediatric population because of the close proximity of the appendix and the umbilicus.
The single-port assisted technique uses one rigid endoscope with a working channel. The third port usually required for the retraction of the appendix is replaced by a sling suture that is put through the anterior abdominal wall in the right lower quadrant. The sling is then utilized to pull the appendix to the abdominal wall in order to provide the tension needed to perform the appendectomy intracorporeally. However, in order to place the transabdominal sling suture, the skin must be transversed twice with a needle to elevate the appendix to the abdominal wall.
Thus, it would be desirable to provide an improved laparoscopic technique that reduces the number of ports needed to perform laparoscopic surgery.
In addition, recent advances in laparoscopic surgical techniques have also allowed certain laparoscopic surgeries to be performed intraluminally, i.e., where access is gained through a natural orifice such as the vagina, rectum or esophagus. Thus, it would also be desirable to provide an improved technique for performing laparoscopic surgery intraluminally through a natural orifice.